The Ethics of Actually Helping People: Targeting Skill Acquisition Goals That Promote Meaningful Outcomes for Individuals with Autism Spectrum Disorder

Abstract

As a field that predominately supports individuals with autism spectrum disorder (ASD), we have an ethical duty as behavior analysts to ensure that the goals we write and interventions we prescribe promote best outcomes across the lifespan. This is critical, given that as it stands now, outcomes in adulthood for individuals with ASD are poor in every area assessed. The Ethics Code for Behavior Analysts can be interpreted to provide support for teaching the right goals, the right way, with respect to inherent rights of those we serve, in order to help affect positive changes in these outcomes. The present article highlights ethical themes that are relevant in order to affect these changes that are supported by the Code, as well as actionable steps to take next. The aim is to provide a resource for practitioners to use in clinical practice and in making ethical decisions that will help to improve outcomes for individuals with autism in adulthood. In addition, recommendations are made about integrating these values and approaches in terms of training, supervision, advocacy, and research.

In the chapter, “The Ethics of Helping People,” B. F. Skinner (1975/1996) stated, “One has most effectively helped others when one can stop helping them altogether" (p. 63). As a logical extension, to most effectively help individuals with autism spectrum disorder (ASD),1 we must ensure that they are adequately prepared for as independent a life as possible across their lifespan. This is important given that, as it stands now, outcomes in adulthood for individuals with ASD are generally poor in every area assessed, including postsecondary education, employment, independent living, social and community participation, access to services, and health and safety (Lai et al., 2019; Orsmond et al., 2013; Roux et al., 2015; Schroeder et al., 2014; Shattuck et al., 2012). These outcomes are worse than typically developing individuals as well as those with other disability labels (Roux et al., 2015), and have shown little improvement over the years (Howlin, 2021; Newman et al., 2010; Shattuck et al., 2020). Recent research suggested that about half of adults on the autism spectrum had poor outcomes based on a variety of measures, and less than a quarter had well-integrated lives characterized by quality outcomes (Mason et al., 2021; Steinhausen et al., 2016). In addition, the quality of life (QoL) of adults with autism has been reported as being generally lower than that of typically developing adults when tools designed for the general population are used (Ayres et al., 2018).

As of late 2020, 73.16% of Behavior Analyst Certification Board (BACB) certificants (i.e., BCBA-D, BCBA, BCaBA, and RBT) identified their primary area of professional emphasis as ASD (BACB, n.d.). Given that about three quarters of the field of applied behavior analysis (ABA) primarily works with individuals with ASD, it seems reasonable to interpret our ethical guidelines in terms of directing best practice within this specific population. As behavior analysts, we are arguably ethically bound to ensure that the goals we write and the interventions we prescribe promote quality outcomes across the lifespan for those that we serve. As such, the purpose of the present article is to: (1) draw attention to the problem of poor adult ASD outcomes and the attainable, yet insufficiently employed solution of effectively teaching the right skills the right way; (2) describe potential unintended contributions to this problem; (3) propose how behavior analytic practice can contribute to the solution, if guided by two major ethical themes supported by expanded applications of the most recent Ethics Code (BACB, 2020); and (4) present the field of behavior analytic intervention with a call to action targeted at ensuring adequate resources are available for advocacy, dissemination, networking, and expertise of current and future practitioners who choose to work with individuals with autism. Throughout this article, references to specific ethical standards and core principles from the Ethics Code for Behavior Analysts (BACB, 2020) are made in parentheses following statements or ideas to which the authors consider them applicable. In these instances, it is suggested that the reader (1) refer to Table 1, which provides an overview of each standard as written in the Code (BACB, 2020) as well as additional interpretations that are suggested; and (2) refer to Table 2, which provides the core principles exactly as written in the Code (BACB, 2020) so that they may be quickly accessed and read critically, allowing for suggested interpretations to be considered.

Table 1.

Proposed additional interpretations of standards within the ethics code for behavior analysts

BACB Ethics Code for Behavior Analysts (2020) Standard		Additional Interpretations
Section 1: Responsibility as a Professional
1.05	Practicing within Scope of Competence Behavior analysts practice only within their identified scope of competence. They engage in professional activities in new areas (e.g., populations, procedures) only after accessing and documenting appropriate study, training, supervised experience, consultation, and/or co-treatment from professionals competent in the new area. Otherwise, they refer or transition services to an appropriate professional.	• Behavior analysts’ competence may include specific age groups within populations they serve, including assessments used, goals targeted, and interventions used within these groups. • In addition, ethical behavior requires both clinical judgement and the worldview of a radical behavior analyst, which include core competencies such as the ability to make in the moment decisions based on the behavior of our clients and changes in their environment, to think outside of the box, and the ability to truly individualize treatment. (same for 3.03 and 4.02)
Section 2: Responsibility in Practice
2.01	Providing Effective Treatment Behavior analysts prioritize clients’ rights and needs in service delivery. They provide services that are conceptually consistent with behavioral principles, based on scientific evidence, and designed to maximize desired outcomes for and protect all clients, stakeholders, supervisees, trainees, and research participants from harm. Behavior analysts implement nonbehavioral services with clients only if they have the required education, formal training, and professional credentials to deliver such services.	• Behavior analysts should prioritize clients’ rights to behavioral programming that emphasizes targeting and prioritizing functional skills and personal welfare. • Behavior analysts should promote outcomes that are socially valid across the lifespan. • In considering the long-term outcomes of treatment that is meaningful, behavior analysts should promote outcomes that are generalized over time and across various environments.
2.09	Involving Clients and Stakeholders Behavior analysts make appropriate efforts to involve clients and relevant stakeholders throughout the service relationship, including selecting goals, selecting and designing assessments and behavior-change interventions, and conducting continual progress monitoring.	• Behavior analysts should ensure that skill acquisition targets are selected with not for clients and stakeholders; these skills should be valuable to current and future environments and promote long-term well-being and happiness. • Behavior analysts should continually seek validation from clients and stakeholders on the skills targeted, the procedures used, and the outcomes of treatment.
2.13	Selecting, Designing, and Implementing Assessments Before selecting or designing behavior-change interventions behavior analysts select and design assessments that are conceptually consistent with behavioral principles; that are based on scientific evidence; and that best meet the diverse needs, context, and resources of the client and stakeholders. They select, design, and implement assessments with a focus on maximizing benefits and minimizing risk of harm to the client and stakeholders. They summarize the procedures and results in writing.	• Behavior analysts should take into account the client’s age, developmental level, and functional/adaptive skills currently in their repertoire when choosing skill-based assessments. • Behavior analysts should utilize skill-based assessments as a guide to develop highly individualized programming but focus on all relevant factors pertaining to promoting best long-term outcomes for the client. • Behavior analysts should utilize clinical judgement to make decisions related to design and implementation of assessments.
2.14	Selecting, Designing, and Implementing Behavior-Change Interventions Behavior analysts select, design, and implement behavior-change interventions that: (1) are conceptually consistent with behavioral principles; (2) are based on scientific evidence; (3) are based on assessment results; (4) prioritize positive reinforcement procedures; and (5) best meet the diverse needs, context, and resources of the client and stakeholders. Behavior analysts also consider relevant factors (e.g., risks, benefits, and side effects; client and stakeholder preference; implementation efficiency; cost effectiveness) and design and implement behavior-change interventions to produce outcomes likely to maintain under naturalistic conditions. They summarize the behavior-change intervention procedures in writing (e.g., a behavior plan).	• Behavior analysts are expected to identify evidence-based interventions in such complex areas of human competence as independence, safety, self-management, communication, time management, self-care, employment, etc., the acquisition of which may be associated with more positive overall outcomes in adulthood. • Behavior analysts should take into consideration the chronological age of the client, his or her preferences and deficits, and the demands of current and future environments when choosing skill-acquisition targets. • Behavior analysts should not choose skill-acquisition targets based on their sequential order or simple presence within a skill-based assessment; targeted skills should be highly individualized to what is most meaningful for that particular client. • Despite the fact that more complicated procedures may be required to target community-based adaptive skills, the correct procedures to target the most meaningful goals should always be used when at all possible, in order to benefit the client. This most often means using real materials and practicing in the environment where the skill will ultimately take place. • In order to minimize the challenges to behavior change programs that are inherent in less contrived environments such as a client’s home, community, or place of employment, the following considerations should be made when designing skill-acquisition interventions: (1) the context in which instruction takes place; (2) the intensity of instruction necessary for the skill to be acquired; (3) the efficiency of instruction, such that the least amount of response effort to be effective is required; and (4) the value of the skill to the individual. • Behavior analysts are expected to develop behavior change goals that are socially valid and to identify potentially effective intervention strategies that are evidence-based and acceptable to the community at large.
2.15	Minimizing Risk of Behavior-Change Interventions Behavior analysts select, design, and implement behavior-change interventions (including the selection and use of consequences) with a focus on minimizing risk of harm to the client and stakeholders. They recommend and implement restrictive or punishment-based procedures only after demonstrating that desired results have not been obtained using less intrusive means, or when it is determined by an existing intervention team that the risk of harm to the client outweighs the risk associated with the behavior-change intervention. When recommending and implementing restrictive or punishment-based procedures, behavior analysts comply with any required review processes (e.g., a human rights review committee). Behavior analysts must continually evaluate and document the effectiveness of restrictive or punishment-based procedures and modify or discontinue the behavior-change intervention in a timely manner if it is ineffective.	• Behavior analysts should note that risks include those risks associated with poor outcomes in adulthood related to complex areas of human competence such as independence, safety, self-management, communication, time management, self-care, employment, etc.; the most essential and meaningful skills possible should be targeted to positively avoid such risks. • Behavior analysts should note that individuals of diverse abilities also have the right to the dignity of risk; situations involving appropriate and reasonable risk can, and should, be incorporated into programming of those we serve; this dignity of risk should always be balanced with education, preparation and appropriate safety precautions.
2.18	Continual Evaluation of the Behavior-Change Intervention Behavior analysts engage in continual monitoring and evaluation of behavior-change interventions. If data indicate that desired outcomes are not being realized, they actively assess the situation and take appropriate corrective action. When a behavior analyst is concerned that services concurrently delivered by another professional are negatively impacting the behavior-change intervention, the behavior analyst takes appropriate steps to review and address the issue with the other professional.	• Behavior analysts should prioritize long-term outcomes by making necessary changes to skill acquisition programming if sufficient progress is not being made, in order for the client to more quickly master meaningful skills that will lead to more opportunities in adulthood.
Section 3: Responsibility to Clients and Stakeholders
3.01	Responsibility to Clients Behavior analysts act in the best interest of clients, taking appropriate steps to support clients’ rights, maximize benefits, and do no harm. They are also knowledgeable about and comply with applicable laws and regulations related to mandated reporting requirements.	• Client’s rights include those related to quality of life, which behavior analysts should assess and seek to systematically increase for each individual client. • Behavior analysts should begin all programmatic decisions with quality of life in adulthood in mind and seek to use our science for its intended purpose of improving the lives of those we serve. • Programming should always be aimed at ways in which clients can safely and effectively increase access to those items, activities, people, or environments important to them; this includes the right to have, and be treated with, dignity by those around them and even society at large. The ethical behavior analyst should always speak and behave in ways that uphold the innate dignity of all clients. • Consideration should be made to applicable laws designed to promote and protect the rights of individuals with disabilities is important, such as those that call for the rights of all to enjoy independence, choice making, inclusion within the community, integration into all aspects of society at large including making contributions to that society, and access to interdependent relationships and a life enriched with leisure and social opportunities, amongst other rights.
3.03	Accepting Clients Behavior analysts only accept clients whose requested services are within their identified scope of competence and available resources (e.g., time and capacity for case supervision, staffing). When behavior analysts are directed to accept clients outside of their identified scope of competence and available resources, they take appropriate steps to discuss and resolve the concern with relevant parties. Behavior analysts document all actions taken in this circumstance and the eventual outcomes.	• Behavior analysts’ competence may include specific age groups within populations they serve, including assessments used, goals targeted, and interventions used within these groups. • In addition, ethical behavior requires both clinical judgement and the worldview of a radical behavior analyst, which include core competencies such as the ability to make in the moment decisions based on the behavior of our clients and changes in their environment, to think outside of the box, and the ability to truly individualize treatment.
3.12	Advocating for Appropriate Services Behavior analysts advocate for and educate clients and stakeholders about evidence-based assessment and behavior- change intervention procedures. They also advocate for the appropriate amount and level of behavioral service provision and oversight required to meet defined client goals.	• In advocating for clients, behavior analysts should ensure that they advocate for services that are socially valid, meaningful, applied in nature, and promote quality long-term outcomes in adulthood. • Behavior analysts should also advocate for service delivery models to increase beyond childhood years to meet the needs of clients who require services across the lifespan, including advocating for improvements in the recruitment, retention, and training of staff across all settings.
Section 4: Responsibility to Supervisees and Trainees
4.02	Supervisory Competence Behavior analysts supervise and train others only within their identified scope of competence. They provide supervision only after obtaining knowledge and skills in effective supervisory practices, and they continually evaluate and improve their supervisory repertoires through professional development.	• Behavior analysts’ competence may include specific age groups within populations they serve, including assessments used, goals targeted, and interventions used within these groups. • In addition, ethical behavior requires both clinical judgement and the worldview of a radical behavior analyst, which include core competencies such as the ability to make in the moment decisions based on the behavior of our clients and changes in their environment, to think outside of the box, and the ability to truly individualize treatment.
4.06	Providing Supervision and Training Behavior analysts deliver supervision and training in compliance with applicable requirements (e.g., BACB rules, licensure requirements, funder and organization policies). They design and implement supervision and training procedures that are evidence based, focus on positive reinforcement, and are individualized for each supervisee or trainee and their circumstances.	• Behavior analysts should include training in less contrived environments (i.e., in the environment where the skill is to be used) in a manner that best promotes the correct implementation of behavior change programs for their clients. • High quality training is necessary in order to ensure that staff find their job inherently reinforcing and avoid burnout and high turnover rates. • Training should be provided for all necessary trainees, including non-behavior-analytic staff such as those in other disciplines, as well as families who may aid in teaching of certain skills for generalization purposes.

Table 2.

Core Principles from The Ethics Code for Behavior Analysts (BACB, 2020, p. 4)

Four foundational principles, which all behavior analysts should strive to embody, serve as the framework for the ethics standards. Behavior analysts should use these principles to interpret and apply the standards in the Code. The four core principles are that behavior analysts should: benefit others; treat others with compassion, dignity, and respect; behave with integrity; and ensure their own competence
1	Benefit Others. Behavior analysts work to maximize benefits and do no harm by:	• Protecting the welfare and rights of clients above all others • Protecting the welfare and rights of other individuals with whom they interact in a professional capacity • Focusing on the short- and long-term effects of their professional activities • Actively identifying and addressing the potential negative impacts of their own physical and mental health on their professional activities • Actively identifying potential and actual conflicts of interest and working to resolve them in a manner that avoids or minimizes harm • Actively identifying and addressing factors (e.g., personal, financial, institutional, political, religious, cultural) that might lead to conflicts of interest, misuse of their position, or negative impacts on their professional activities • Effectively and respectfully collaborating with others in the best interest of those with whom they work and always placing clients’ interests first
2	Treat Others with Compassion, Dignity, and Respect. Behavior analysts behave toward others with compassion, dignity, and respect by:	• Treating others equitably, regardless of factors such as age, disability, ethnicity, gender expression/identity, immigration status, marital/ relationship status, national origin, race, religion, sexual orientation, socioeconomic status, or any other basis proscribed by law • Respecting others’ privacy and confidentiality • Respecting and actively promoting clients’ self-determination to the best of their abilities, particularly when providing services to vulnerable populations • Acknowledging that personal choice in service delivery is important by providing clients and stakeholders with needed information to make informed choices about services
3	Behave with Integrity. Behavior analysts fulfill responsibilities to their scientific and professional communities, to society in general, and to the communities they serve by:	• Behaving in an honest and trustworthy manner • Not misrepresenting themselves, misrepresenting their work or others’ work, or engaging in fraud • Following through on obligations • Holding themselves accountable for their work and the work of their supervisees and trainees, and correcting errors in a timely manner • Being knowledgeable about and upholding BACB and other regulatory requirements • Actively working to create professional environments that uphold the core principles and standards of the Code • Respectfully educating others about the ethics requirements of behavior analysts and the mechanisms for addressing professional misconduct
4	Ensure their Competence. Behavior analysts ensure their competence by:	• Remaining within the profession’s scope of practice • Remaining current and increasing their knowledge of best practices and advances in ABA and participating in professional development activities • Remaining knowledgeable and current about interventions (including pseudoscience) that may exist in their practice areas and pose a risk of harm to clients • Being aware of, working within, and continually evaluating the boundaries of their competence • Working to continually increase their knowledge and skills related to cultural responsiveness and service delivery to diverse groups

We, as the authors, recognize that ASD represents a complex “spectrum” (American Psychiatric Association, 2013) and that outcomes for individuals on one end of the spectrum will look different than for individuals on the other end, with high degrees of variability in between (Georgiades & Kasari, 2018). In addition, each individual with a diagnosis of autism is unique and likely does not fit neatly into a given category. Regardless, concerns regarding outcomes should be central to making programmatic and intervention decisions. This article offers general recommendations that should be read with attention to how they can be applied to any client, regardless of age, developmental level, or current skills repertoire. Although our recommendations, we believe, apply to all individuals with autism, specific attention should be given to how practitioners can best affect adult outcomes by effectively planning for this transition by teaching the right skills, the right way, as early as possible.2

The Problem of Poor Adult Outcomes and Adaptive Behavior Skills as the Solution

Children with autism become adults with autism. Simply in terms of numbers, we are adults for far longer than we are children. According to the Centers for Disease Control and Prevention (CDC; Xu et al., 2020), the average life expectancy in the United States is 78.7 years. Considering adolescence as beginning at age 12 (Food & Drug Administration [FDA], 2014; Hardin et al., 2017), and presuming a person were to live to the average life expectancy in the United States, this would mean that adolescence and adulthood account for about 86% of our lives, whereas childhood only accounts for about 14%. Despite this fact, there is an alarming disparity in allocation of resources, availability of supports, diversity of research, and a deficit in the field of behavior analysis for serving this age group and for preparing those transitioning to this age group (Anderson et al., 2018; Baker-Ericzén et al., 2018; Gerhardt & Lainer, 2011; Shattuck et al., 2020). In 2011, Gerhardt and Lainer referred to “a looming crisis of unprecedented magnitude for adults with autism, their families, and the ill-prepared and underfunded adult service system charged with meeting their needs” (p. 37); a decade later, this crisis has arrived and is in full swing.

Individuals with intellectual and developmental disabilities (IDD), including autism, often require lifelong support and, in many cases, 24-hour supervision (President’s Committee for People with Intellectual Disabilities [PCPID], 2017; Roux et al., 2015). Yet, the unfortunate reality is that the transition from childhood to adulthood comes with a huge drop-off in funding and services for individuals with disabilities (Gerhardt & Lainer, 2011; Laxman et al., 2019; Marsack-Topolewski & Weisz, 2020; Roux et al., 2015; Shattuck et al., 2020). This drop-off exists in both the education and insurance-funded worlds, and is so profound that it is often referred to as “falling off a service cliff” (Roux et al., 2015). Although insurance-funded coverage is presently mandated across the United States, many states have limitations in coverage based on age, dollar amount, or hourly service caps for these necessary services, resulting in inequitable access depending on where you live (Autism Speaks, n.d.b). Likewise, although special education and transition services are mandated by federal law ([Individuals with Disabilities Education Act] IDEA, 2004), after graduating from high school there is no clear, national mandate that requires support services in adulthood. For the most part, families are left to fend for themselves and advocate for these supports, which often do not readily exist (Roux et al., 2015; Shattuck et al., 2020).

Given the current state of funding and limited availability of adequate services and supports for adults with autism and other developmental disabilities (Autism Speaks, n.d.b; Vohra et al., 2014), it is of the utmost importance that practitioners maximize the time and resources available during childhood, while rich resources and funding sources are available (e.g., IDEA, 2004; Marsack-Topolewski & Weisz, 2020; Shattuck et al., 2020). In general, young adults on the spectrum are not provided the skills necessary to make a successful transition to life after high school (Eilenberg et al., 2019; Gerhardt & Lainer, 2011; Kuo et al., 2018; Shattuck et al., 2018), so targeting meaningful goals in preparation for adulthood is critical if adult outcomes are to improve. Meaningful goals are individualized, inclusive of the learner’s unique needs and interests, and focused on building independence in both current and future environments (Ayres et al., 2011). A meaningful curriculum assesses an individual’s needs and prioritizes skill acquisition targets based on what is most important to their lives. Many meaningful skill areas include those related to adaptive behavior, which can be categorized as those skills that allow individuals to meet standards of personal independence expected for their age or social group (Heward, 2005).

Adaptive skills have been shown to positively affect outcomes more so than factors such as cognitive level or autism symptom severity (Farley et al., 2009; Szatmari et al., 2003; Yeo & Teng, 2015), particularly when measures such as quality of life and social inclusion are reported (Bishop-Fitzpatrick et al., 2016; Esbensen et al., 2010; Kirby, 2016; Orsmond et al., 2013). Such research has led some to suggest that success in adulthood can be best thought of as the degree of independence one has, making adaptive behavior one way to clearly measure outcomes (Kanne et al., 2011). As Gerhardt et al. (2013) noted, “Adaptive behavior is so central to adult life that it would not be an understatement to say that adaptive behavior will get a person through times of no academic skills better than academic skills will get a person through times of no adaptive behavior” (p. 159). Becoming independent is important, as it often leads to increased access to privacy, choice, and dignity, as well as decreased financial, social, and emotional pressures being placed on others in their lives (Brown et al., 1976; Dell’Armo & Tassé, 2019; Lin, 2011; Marsack-Topolewski et al., 2021). Yet, for individuals on the autism spectrum, research has consistently documented that adaptive behavior deficits are present and substantial, regardless of intellectual level (e.g., Bellini et al., 2007; Szatmari et al., 2003; Tomanik et al., 2007), and that these deficits become more apparent with age (Klin et al., 2007). This suggests where practitioners should focus skill acquisition programming for individuals on the autism spectrum.

Although instruction in adaptive behavior would seem to present, at least partially, a solution to the problem of poor adult outcomes, the benefits of such have yet to be realized (Clarke et al., 2021; Duncan et al., 2021; Farley et al., 2018; Hong et al., 2017; Howlin & Iliana, 2017; King et al., 2020; Lord et al., 2020). This means we are left in a situation where parents, practitioners, and funding sources only realize that, perhaps, they should have done things differently once it’s already too late (e.g., Ghanouni et al., 2021). Significant changes to current systems related to planning and intervention are necessary in order to effectively meet the needs of adults on the spectrum and for preparing those transitioning to adulthood (Gerhardt & Lainer, 2011; Howlin, 2021; Shattuck et al., 2020).

Historical Context to How We Got Here: Unintentional Contributions to the Problem

Given the continued poor outcomes for the majority of adults on the spectrum, it is important to identify the various, well-meaning, and unintentionally problematic contributions to this situation. These contributions can be discussed in terms of the two primary funding streams by which behavior analytic services are resourced (i.e., federal/state-funded education services and medical insurance), each of which come with its own sets of benefits and barriers, as well as early research and focus within the field of behavior analysis. Each of these areas will be briefly reviewed in the following sections.

Special Education Funding Stream: Historical Inclusion Efforts

The contributions of various legal mandates and relevant research that have benefited individuals with disabilities are worth noting. Prior to the deinstitutionalization efforts in the United States in the late 1970s, a common misconception was that individuals with disabilities would not benefit from public education (IDEA, 2004) Both civil rights (i.e., The Rehabilitation Act of 1973, 2010, Sect. 504) and educational entitlement (i.e., Education for All Handicapped Children Act [EHA], Public Law 94–142, 1975; later reauthorized as the Individuals with Disabilities Education Act in 1990; IDEA, 2004) laws were enacted to enable all children with a disability label to access the same educational rights as their typically developing peers, including access to a guaranteed free and appropriate public education (FAPE). During this time, a number of significant contributions to the field were made by researchers and academics who focused on how to best serve this population in school settings (e.g., Brown et al., 1976; Gold, 1980; Haring & Brown, 1976). Continuous inclusion efforts led to educators conducting and publishing research on effective instructional programming for students with disabilities in inclusive settings (e.g., Haring, 1991; Haring & Romer, 1995; Meyer, 1994). These efforts often focused on inclusion in the physical setting sense only, and not in terms of access to the same curriculum or social inclusion as their typically developing peers (Courtade et al., 2012).

A subsequent push for inclusion beyond the physical environment led to research on effective models of inclusion targeting physical, social, and academic inclusion of individuals with disabilities (e.g., Ryndak et al., 1999). At the time, the belief was that the capabilities of students with severe disabilities were being downplayed by teaching various functional skills only, in lieu of providing them the right to the general curriculum content (Courtade et al., 2012). These inclusion efforts eventually led in part to the development of the Common Core State Standards Initiative (see CCSS, 2022), which were intended to ensure that all students were given the right to be prepared for postsecondary education and employment. These standards now require instruction across the United States to adhere to these standards, which can, unfortunately, be in direct opposition to the instruction of more important adaptive behavior skills (see Ayres et al., 2011; Ayres et al., 2012).

However well-intended, the interpretation and follow-through of special education law seems to have taken something of a misstep along the way. Current restrictions to teaching functional skills in place of common core standards are not in line with the early intents of various mandates. For example, The Rehabilitation Act of 1973 (as amended) stated that a disability, “in no way diminishes the right of individuals to: (a) live independently, (b) enjoy self-determination, (c) make choices, (d) contribute to society, (e) pursue meaningful careers, and (f) enjoy full inclusion and integration in the economic, political, social, cultural, and educational mainstream of American society” (The Rehabilitation Act of 1973, 2010; see BACB, 2020, standards 2.01, 2.14, 3.01; core principles 1, 2). In addition, the Developmental Disabilities Assistance and Bill of Rights Act mandated that, “individuals with developmental disabilities have access to opportunities and necessary supports to be included in community life, have interdependent relationships [and] access to and use of recreational, leisure and social opportunities to enrich their participation in community life” (Developmental Disabilities Assistance and Bill of Rights Act of 2000; see BACB, 2020, standards 2.01, 2.14, 3.01; core principles 1, 2).

Likewise, the intent of IDEA was to provide access to the general education curriculum to the extent possible (emphasis added), with one of the purposes being to help all children, “be prepared to lead productive and independent lives, to the maximum extent possible” (IDEA, 2004). It can be argued that the appropriateness and/or meaningfulness of an educational program should be measured by the extent to which independent lives in adulthood are attained (Ayres et al., 2011; Lowrey et al., 2007). As Ayres et al. (2011) noted, “Learning fragments of higher-level academic skills should not be achieved at the cost of learning how to function independently in society” (p. 11). A standards-based focus in place of a functional/adaptive focus can be detrimental to a learner; although grade-level achievement in academic skills may be possible with the help of behavior analysis and/or special education, it may not lead to more independent functioning and meaningful outcomes (Ayres et al., 2011). It is important to consider the cost of a curricular focus that is not centered on individualized gains leading to improvements in quality of life in both current and future environments.

Insurance Coverage Funding Stream: Admirable Initial Achievements

In comparison to education efforts that have spanned decades, the history of insurance funding for behavior analytic services is far less extensive. Early efforts in the field of applied behavior analysis at targeting skill acquisition with individuals with disabilities date back to the late 1940s, with its origins in hospital settings (e.g., Ayllon & Haughton, 1962; Ayllon & Michael, 1959; Fuller, 1949; Isaacs et al., 1960). This was followed by the field of special education accessing this information and promoting its ability to teach new skills to children in a way backed by the science of behavior analysis (Staats & Butterfield, 1965; Wolf et al., 1963; Zimmerman & Zimmerman, 1962). In 1987, Lovaas et al. demonstrated the potential of behavior analytic intervention to teach autistic individuals new skills and, potentially, change their developmental trajectory (and thereby the cost of long-term intervention). This helped propel interventions based on the principles of ABA to the forefront of effective treatment for ASD, leading to the U.S. surgeon general supporting its use in early intervention as an evidence-based treatment (U.S. Department of Health & Human Services, 1999). Through the dedicated efforts of teams of professionals and advocates, insurance-funded coverage for autism became systematically mandated by law across all 50 states in the United States (Autism Speaks, n.d.b).

Despite these incredible gains that have enabled countless individuals on the spectrum access to an extremely valuable set of interventions, many insurance companies restrict funding to only those skills that meet a “medical necessity”3 criterion, which often includes only those with a direct connection to the DSM-V diagnostic criteria of ASD (e.g., social communication/social interaction; restricted/repetitive patterns of behavior, interests, or activities, etc.; American Psychiatric Association, 2013). Although addressing these deficits is important, limiting intervention to these skill domains can result in practitioners failing to target adaptive behavior skills that are necessary for success beyond childhood (Gerhardt et al., 2013). Thus, even if behavior analysts understand the importance of targeting meaningful skills that may positively affect outcomes, they may be restricted from doing so due to inadvertently restrictive practices promulgated by insurance companies and lawmakers. It would appear that the practical and financial benefits of targeting adaptive skills as early as possible in order to positively affect the long-term necessity (and cost) of services into adulthood (Blaxill et al., 2021; Farley et al., 2009; Klin et al., 2007; Murphy et al., 2018; Zerbo et al., 2019) has not been adequately disseminated, or translated into general practice. As such, we have more work to do.

Focus on Early Identified Evidence-Based Skills and Procedures

The use of targets and procedures determined to be evidence-based for use with young children with autism may have been overgeneralized, and unintentionally contributed to the problem at hand. Early intensive behavioral intervention (EIBI), or the “Lovaas treatment approach” (Lovaas, 1987) has for decades been considered a well-established intervention for young children with autism (Eldevik et al., 2009; Odom et al., 2010; Rogers & Vismara, 2008; Wong et al., 2015). This approach has been described as featuring a variety of common elements (see Eikeseth, 2009; Green et al., 2002). Many of these features can be applied to adaptive behavior instruction in natural environments; these include: (1) individualized intervention that is comprehensive across all skill domains; (2) use of numerous behavior analytic procedures used to build skills and reduce interfering behaviors; (3) parents as active co-therapists; (4) 1:1 teaching leading to effective small and large group formats; (5) intervention taking place in the home then gradually transitioning to other relevant environments such as the community (Eikeseth, 2009; Eldevik et al., 2009; Green et al., 2002). However, many other features common to the typical behavior analytic approach used with autistic children may have less impact on adult outcomes. For example, this approach focuses on teaching skills within the normal developmental sequence, with goals of integration into general education settings once clients attain the skills required to function in those settings (Eikeseth, 2009; Eldevik et al., 2009; Green et al., 2002). Although this is appropriate for younger learners who may “catch up” to same-aged peers, for others, a focus on more adaptive behavior skills as early as possible would be far more effective in changing the trajectory of their lives. An overfocus on developmentally sequenced skills, for example, building block skills related to receptive language, matching, gross motor imitation, etc. that are commonly found in discrete trial teaching procedures for young children (often targeted in seated, table-top contexts), will not be appropriate in many cases following the early developmental years.

In addition, a number of skills-based assessments and curricula have been developed over the years in the field of behavior analysis (e.g., Partington, 2006; Sundburg, 2014) that, although valuable in many ways, seem to have also resulted in an overreliance on these tools by some practitioners to guide programming. When that happens, skills targeted for intervention are targeted based on their order or presence within the skills-based assessments and/or curricula, and not upon their relevance to the student or their family. For myriad reasons, this can be inappropriate and ineffective. As a general rule, it appears that developmentally sequenced tools are often used in place of more functional skills-based tools, which may be more appropriate given a client’s need.

Furthermore, behavior analytic training that does not include flexibility, in-the-moment decision making, or an understanding of the client as a person and not simply a collection of behaviors may also result in rigid adherence to the use of published assessment tools and an overemphasis on compliance instead of independence and self-determination (e.g., Leaf et al., 2016b), some of which has been at the root of our field’s negative perception (e.g., Bottema-Beutel et al., 2021; Shyman, 2016). This seems incompatible with various rights to exercise personal preferences and to live a life of competence, dignity, and quality (e.g., Bannerman et al., 1990; Reid et al., 2017; Winnet & Winkler, 1972) or the clinical judgment skills that characterized early radical behaviorists who shaped our field (Leaf et al., 2016b, 2019).

Responsibility of Behavior Analysts in Contributing to a Solution: Ethical Requirements

Behavior analysts are in a position to help affect the necessary changes in adult autistic outcomes by targeting the right skills using the right procedures, and are ethically bound to do so. This is supported by the early outlines of our field that suggest that clients have a right to treatment that is highly individualized, teaches applied skills, promotes happiness and well-being, and supports favorable long-term/generalized outcomes (see Baer et al., 1968; Bannerman et al., 1990; Schwartz & Baer, 1991; Van Houten et al., 1988; Wolf, 1978) as well as empirical evidence that suggests that specific skills taught can affect outcomes (Eilenberg et al., 2019; Gerhardt & Lainer, 2011; Matthews et al., 2015; Shattuck et al., 2018). As will be reviewed in a later section, still relevant historical contributions and calls to action from related disciplines generally support the same values. These core values can be translated into practice guidelines that can be applied when serving all clients, starting at a young age, leading up to preparing for the transition to adulthood. Such guidelines are supported by the Ethics Code for Behavior Analysts (BACB, 2020).

In lieu of a separate BACB autism credential, or a separate Ethics Code for autism practitioners, our current ethical guidelines (BACB, 2020) can be interpreted as including recommendations for the promotion of best practice with autistic individuals, despite the Code not being designed for use with any one population/area. To support this, the Code (BACB, 2020) includes the following relevant and practical statement: “The standards included in the Code are not meant to be exhaustive, as it is impossible to predict every situation that might constitute an ethics violation. Therefore, the absence of a particular behavior or type of conduct from the Code standards does not indicate that such behavior or conduct is ethical or unethical. When interpreting and applying a standard, it is critical to attend to its specific wording and function, as well as the core principles” (p. 5). Therefore, changes to the newest version of the Code (BACB 2020) are not directly suggested but, rather, it is recommended that members of our field consider extending its applications. As such, the overarching core principles, as well as a number of specific code standards, support recognition of the following proposed best practice themes that could help to improve outcomes for individuals with ASD whom we serve. The two major best practice themes proposed are: (1) What skill is targeted for acquisition? In other words, we need to be intentional in choosing what skills we target; and (2) How do we most effectively teach this skill? We need to be intentional and evidence-based when choosing how we teach these skills. Each of these themes will be described in detail in the following sections, with references made to both specific code items and core principles that support it.

Best Practice Theme #1: Intentionally Choosing What We Teach

To begin with, when interpreting our ethical guidelines, behavior analysts should be sure to recognize that references made to “behavior change” throughout the Code not only apply to behavior reduction programming, but also to skill acquisition programming. Although many BCBAs work in settings in which conducting functional analyses and writing functionally related behavior plans to reduce and replace challenging behavior is their primary role, many others are responsible for their clients’ skill acquisition programming in one form or another. Although the Code emphasizes effective treatment throughout its guidelines (see BACB, 2020, standards 2.01, 2.14, 2.18), it is important to remember that “Despite how evidence-based your interventions are, teaching inconsequential skills well is really no better than teaching essential skills poorly” (Gerhardt, 2008). In other words, what we teach needs to be as important as how we teach. Acquisition of those skills that promote independence in current and future environments has been linked to more positive outcomes for adults on the spectrum (Bolte & Poustka, 2002; Paul et al., 2004). Behavior analysts are able to help because (as previously stated) our science has decades of research supporting our ability to increase skills in these areas (e.g., Allen et al., 2010; Lambert et al., 2016; Matson et al., 2012; Van Laarhoven et al., 2010). Thus, if improved quality of life is (as it should be) the overall goal, then skill-acquisition programs should include interventions in complex areas of human competence such as independence, safety, social skills, self-management, communication, time management, self-care, employment, etc., the acquisition of which are generally associated with greater success in adulthood. In determining what to teach, practitioners should consider the diverse needs of the client, such as their chronological age, preferences, strengths, challenges, and the demands of current and potential future environments (see BACB, 2020, standards 2.01, 2.14, 2.15, 3.01; core principles 1, 2). Paraphrasing the criterion of ultimate functioning (Brown et al., 1976) discussed later, the standard to which we should hold skill acquisition for quality outcomes in adulthood is: “anything that if you can’t do, someone else will have to do for you” (Ayres et al., 2011). In choosing what to teach, using this criterion as our standard is a great way to start.

Although the Code instructs behavior analysts to provide services that maximize desired outcomes (i.e., BACB, 2020, standard 2.14), the interpretation of the term “outcomes” should be expanded to include outcomes that are generalized over time and across various environments, especially as that pertains to adulthood. These outcomes are critically important when considering the long-term implications of treatment for which generalization is nonexistent. For example, learning to brush one’s teeth thoroughly is beneficial across the lifespan in that it enables less reliance on others, promotes good oral health, and prevents potential harm or risk that may come with the need for intrusive procedures such as going under general anesthesia to undergo a cleaning or cavity filling. In contrast, achieving mastery in labeling 200 pictures, only 100 of which they may encounter in real life, may provide few long-term, socially valid effects on the client’s life (not to mention, there is little evidence to support generalization from labeling pictures to labeling real-life objects, e.g., Bak et al., 2021). In many cases, quality, not quantity should be emphasized when choosing goals that lead to socially valid, long-term outcomes.

In thinking about the prioritization of skills in decision making, practitioners can utilize various planning tools to help map out what skills are most relevant in terms of their long-term applications (e.g., Wehman & Kregel, 2020; Ford et al., 2005). For example, if a long-term goal is to live in a shared-living setting in adulthood, practitioners can backward-chain from this goal and systematically target skills across the lifespan that will get the client to this long-term outcome (Gerhardt & Bahry, 2022; Gerhardt et al., 2013; Ford et al., 2005; Wehman & Kregel, 2020). In this way, preparation for adulthood can begin as early as possible, with long-term thinking being conceptualized as, “adulthood begins in preschool” (Gerhardt, 2019). Identifying “checkpoints” to prompt the regular determination that progress is being made towards these long-term goals, and systematically making adjustments to this plan as needed depending on progress (e.g., 5-year plans, 1-year plans, 6-month plans) is recommended (see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 2.18, 3.01; core principles 1, 2).

Social Validity at the Center

Behavior analysts should begin all programmatic decisions with social validity and quality of life in adulthood in mind, prioritizing client well-being and happiness (Green & Reid, 1996; Schwartz & Baer, 1991; Wolf, 1978; see BACB, 2020, standards 2.01, 2.09, 2.14, 3.01, 3.12; core principles 1, 2). After all, that was what behavior analysis originally pledged as its purpose—targeting behaviors that matter to the individual (Baer et al., 1968; Wolf, 1978). The ethical behavior analyst recognizes that each autistic person is an individual, considers all aspects of the person and his or her environments, and seeks to change only those behaviors that are of social importance to both the individual and their family that will directly, or indirectly, improve their quality of life both now and in their future (Schwartz & Baer, 1991; Wolf, 1978; see BACB, 2020, standards 2.09, 2.14, 3.01, 3.12; core principle 1). Self-selection of priorities and self-determination are essential values on which intervention is built and may more accurately reflect the wishes of the individual (see BACB, 2020, standards 2.09, 3.01, 3.12; core principles 1, 2). It is important to note that an effective skill acquisition program combines high-value and low-value targets, so behavior analysts should take this into consideration as well. Skills that are valued by the individual are more likely to be maintained once they are acquired, but even skills that are not valued may be of importance in supporting engagement, competence, enjoyment, and safety (Gerhardt et al., 2013).

In addition to the client themselves, the input of the parent and/or other family member(s) can provide an invaluable resource to selecting goals that matter. Familial input can help to ensure goals are meaningful, including providing opportunities to integrate cultural considerations and idiosyncrasies of the client and family into practice (Ennis-Cole et al., 2013). In addition, family input may help to positively affect the family’s quality of life. Related to adaptive behavior skills, a growing body of literature supports the importance of adolescents and adults achieving functional independence to support parental well-being (e.g., Cappe et al., 2018; Fong et al., 2020; Lin, 2011). For example, Marsack-Topolewski et al. (2021) found that independence with completing various daily living skills was a statistically significant predictor of decreased caregiver burden. Thus, it would appear that a focus on specific skills that matter to both the client and the family can lead to improved outcomes for all consumers (see BACB, 2020, standards 2.01, 2.09, 2.14; core principles 1, 2).

Skill Acquisition Assessments and Curricula: Guides, Not Roadmaps

Although not explicitly stated in the Code when referring to assessments, any interpretation of the word “assessment” should include both functional behavior assessments and skill-based assessments (see BACB, 2020, standards 2.13, 3.01; core principle 1). Skill-based assessments can be useful in establishing a baseline level of skills from which progress can be tracked after the start of intervention. Choosing which assessment to use can have implications on the goals identified, so this decision should be made carefully. Depending on each client’s unique needs, behavior analysts are encouraged to make individualized decisions, asking themselves a number of questions such as: How old is the client? Do they have an effective form of communicating their wants and needs? What are their greatest skill deficits? Do they engage in dangerous challenging behavior? How likely is it they will “catch up” to same-aged peers? Do they have the most essential/critical skills in their repertoire? What context-related demands are in place (e.g., city living vs. small-town living)? Depending on the answers to these questions and others, a decision can be made regarding what assessment/curriculum path to take (if any). In terms of available skills-based assessments/curricula, these two paths can be thought of as developmental and functional.

In general, developmental assessments present skills in the order they naturally progress in typically developing individuals, with an aim of bringing the client’s skill repertoire closer to that of same-aged peers (e.g., Verbal Behavior-Milestones Assessment and Placement Program [VB-MAPP]; Sundburg, 2014; Assessment of Basic Language and Learning Skills-Revised [ABLLS-R]; Partington, 2006). Developmental assessments/curricula can be beneficial when used with the right client (i.e., those who demonstrate a likelihood of catching up to these same-aged peers). However, because there are many other skills in addition to early learning developmental milestones that are vital to everyday independent living, practitioners should consider utilizing functional skills assessments and/or curricula as well (e.g., Essential for Living: A Communication, Behavior, and Functional Skills Curriculum, Assessment and Professional Practitioner’s Handbook for Children and Adults with Moderate-to-Severe Disabilities [EFL], McGreevy et al., 2014; Community-Based Skills Assessment [CSA], Autism Speaks, 2014; also see Bondy, 2014), depending on each client’s individual needs. Although it is never too early to being targeting functional or adaptive skills, there is a time when it is too late. We must ensure that we are not prioritizing developmental milestones over critical skills that will have an impact on independence in current and future environments.

Skill-based assessments should be utilized with reference to all relevant factors associated with promoting the best long-term outcomes for the client (see BACB, 2020, standards 2.01, 2.09, 2.13, 3.01; core principle 1). Targets should not be automatically chosen based on their sequential order or simple presence within a skill-based assessment. Instead, targeted skills should be highly individualized to what is most meaningful for that particular client. Clinical judgment should be used to make such decisions. For example, a 19-year-old client should not remain focused on seated table work labeling pictures of nouns and verbs for the sole purpose of increasing their number of acquired tacts to 200, thereby mastering Level 2 of the VB-MAPP (Sundburg, 2014) when they cannot get dressed independently, use the bathroom without assistance, or engage in independent leisure skills safely. Filling in squares on assessment charts such as the VB-MAPP (Sundburg, 2014), AFLS (Partington & Mueller, 2016), ABLLS-R (Partington, 2006), etc. should not be the practitioner’s reinforcer; instead, individualized gains that are specifically meaningful to their lives should be the goal (see BACB, 2020, standards 2.01, 2.09, 2.13, 2.14, 2.18, 3.01; core principles 1, 2). Behavior analysts should also recognize that just because a goal came from a “functional” skills assessment does not mean that goal is necessarily functional for a particular client. For example, the AFLS (Partington & Mueller, 2016) may include a skill for zippering a jacket and although this is meaningful for someone who lives in the Northeast, if a learner lives in Southern California, zippering may not be important to their life, so it’s possible that valuable instructional time should not be wasted on it. In addition, if a unique need is brought up by the family or client themselves, this need should not be given less priority simply because the skill is not present within a skill-based assessment (see BACB, 2020, standards 2.01, 2.09, 2.13, 3.01; core principles 1, 2).

It is important to note that behavior analysts should not use the same assessments for every client. Instead, they should seek input from colleagues or continuing education opportunities to expand their assessment repertoire. In some cases, implementing the same assessment with every client, without taking individual needs into account may constitute practicing outside of one’s competence (see BACB, 2020, standards 1.05, 2.13, 3.03; core principles 1, 4). For example, if a clinician has spent their career working with toddlers, and then uses the same assessment/curriculum with a teenage client, this would be inappropriate and result in a loss of social validity for developed goals. As recommended in the Code, behavior analysts should only practice in new areas after they have received sufficient training, consultation, co-treatment, etc. from someone who is competent in that area (BACB, 2020, p. 9; see standards 1.05, 3.03, core principles 1, 4; BACB, 2020). In general, it would be ideal if assessment and curriculum development are best understood as independent processes; this helps to avoid the circular process of “teaching to the test” and allows for objective assessment and more meaningful curricula development. Assessments are not meant to be all-inclusive, and behavior analysts are encouraged to routinely think outside of the box. What is meaningful for some is not meaningful for all. Emphasis should be placed on using assessments as guides, not roadmaps in creating meaningful objectives for clients.

Best Practice Theme #2: Intentionally Choosing How We Teach

Along with choosing the right goals for skill acquisition programs, choosing the right interventions are also of primary importance. First, in designing skill acquisition interventions, behavior analysts should, of course, remember that what may be appropriate for younger learners may not be appropriate for older learners (see BACB, 2020, standards 1.05, 2.01, 2.14 3.01; core principles 1, 2, 4). For example, physical prompting may not be appropriate for teenagers or young adults in the same way it may be for toddlers. Additionally, behavior analysts should speak and behave in ways that reflect dignity for all, with specific attention given to how interactions should shift when working with adults (Reid et al., 2017). Although less extensive when compared to younger learners, there is a growing body of research that supports the use of behavior analytic intervention with older individuals with ASD (Roth et al., 2014) including such procedures as modeling (Allen et al., 2010), chaining (Lambert et al., 2016), prompting (Van Laarhoven et al., 2010), differential reinforcement (Sigafoos et al., 2009), and shaping (Shabani & Fisher, 2006), all of which can be used to teach highly important adaptive behavior skills relevant into adulthood. It is important that these core behavior analytic procedures be used to ensure that the correct procedures to target the most meaningful goals are used, in order to benefit the learner (see BACB, 2020, standards 1.05, 2.01, 2.14, 3.01; core principles 1, 2, and 4). In particular, considerations should be made to the following areas: (1) the context in which instruction takes place; (2) the intensity of instruction necessary for the skill to be acquired; and (3) the efficiency of instruction, such that the least amount of response effort to be effective is required (Gerhardt et al., 2013).

Context

Teaching those complex skills associated with competent adulthood most often means using real materials and teaching in real environments. Brown et al. (1976) noted:

However cumbersome, time consuming, inconvenient or expensive it may be to do so, the pegs, felt squares, pictures of money, tokens, pictures, edible consequences and many, if not all, of the commercially available kits and irrelevant paper and pencil tasks should be faded out. Real money, real streets and cars, real people, real stores, real sounds and smells, real tools and objects, real group homes, real world settings, real appliances and utensils, real motor skills and real ridicule, rejection, and disappointments must replace them. (p. 14)

Despite this call to action over 45 years ago, pegs, pictures, tokens, and edibles continue to run rampant in skill acquisition programming within the fields of special education and applied behavior analysis, with seemingly little consideration of the detrimental long-term outcomes of using methods and materials that fail to generalize (see Bak et al., 2021). Because generalization often does not occur without being directly programmed for in individuals with disabilities, including ASD, it is to the benefit of the learner for teaching to take place in the environment where the skill will ultimately take place (Gerhardt et al., 2013; MacDuff et al., 1993; Neely et al., 2016; Phillips & Vollmer, 2012; Stokes & Baer, 1977). Although sometimes mock materials or contrived environments may be necessary for certain skills and/or certain learners initially, practitioners should ensure that this is a stepping stone and not an endpoint; efforts should be continually made towards using real materials in real environments, with changes being made to programming as needed to promote efficient outcomes (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2).

Targeting complex community-based skills in the natural environment, and not just seated at a desk in contrived environments is critical (Gerhardt & Lainer, 2011; Steege et al., 2007). For example, instruction in completing a purchasing routine requires the use of shaping, prompting, and differential reinforcement in the community where the reinforcer is the item they are purchasing, as opposed to seated in a classroom or clinic using conventional discrete trial teaching (DTT; Leaf et al., 2016a) and reinforcing with tokens (e.g., mass trials of “this bag of chips cost $2, you have $4, do you have enough money?”). Teaching adaptive behavior skills in natural environments may necessarily be more complex given the high level of uncontrollable variables that exist in natural environments (e.g., distracting sounds, unpredictable interactions of community members, unexpected changes in routines). Variables such as the level of complexity of the skill being taught may influence both the components and duration of training needed for those who will implement these procedures (Rispoli et al., 2011). As such, behavior analysts should ensure training takes place in these complex environments with all necessary trainees, including non-behavior-analytic staff such as those in other disciplines, as well as families who may aid in the teaching of certain skills for generalization (see BACB, 2020, standards 4.02, 4.06; core principles 1, 2, 4). Although important in all behavior analytic programming, this necessitates training to include progressive approaches that emphasize responding to the behavior of the individual, assessing reinforcer preferences in the moment, and making quick decisions to adjust programming, as needed (Leaf et al., 2016b; see BACB, 2020, standards 1.05, 2.01, 2.14, 2.18; core principles 1, 2, 4).

Intensity

Individuals with ASD often require a certain level of instructional intensity to master skills. Although this appears to be widely accepted based on the intensity with which seated-at-a-desk DTT trials are often run in controlled settings (e.g., 10 trials per skill, per session), behavior analysts need to generalize this understanding to important adaptive skills that require teaching in natural contexts, such as the community (Gerhardt et al., 2013; Linstead et al., 2017). Community-based instruction has a substantial research base (Walker et al., 2010) that supports its use with individuals with disabilities. We cannot reasonably expect clients to master community-based objectives by providing an insufficient number of practice opportunities each week (e.g., Almalky, 2018; Pickens & Dymond, 2014). In settings that have restrictions on teaching in natural environments, behavior analysts must work to advocate for sufficient practice to be afforded, if we expect learners to master important adaptive behavior skills that will be relevant in adulthood (see BACB, 2020, standards 2.01, 2.14, 2.15, 3.12; core principles 1, 2, 4).

Efficiency

In terms of efficiency, behavior analysts should also ensure that programming targets community-accepted rates, latencies, and durations (Brown et al., 1976). This aspect of social validity is extremely important. For example, when teaching grocery shopping, it may be most appropriate to ask a cashier in a store what they think the most important customer skills are. It is typical, although not exclusively, that this might include the speed with which a customer produces their credit card and pays for their items. In this case, fluency and short duration should be prioritized in training (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2, 4).

At a minimum, workaround adaptations should always be considered to decrease the response effort of skills intended to increase the likelihood and speed with which skills are mastered (Gerhardt et al., 2013). This is especially important if most society members use these adaptations regularly, particularly by making use of the most updated technologies. For example, teaching purchasing using a credit card, gift card, or Apple Pay instead of spending years teaching the value of coins/bills with the aim of teaching purchasing using cash, using shortcuts in a smartphone to make a voice or video call instead of memorizing phone numbers, making use of a phone’s global positioning system to find directions home instead of memorizing how to get to locations, or using ride share applications instead of teaching a complicated public transportation skill (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2, 4).

Although data-based decision making is a regular part of behavior analytic practice (Baer et al., 1968; Slocum et al., 2014) behavior analysts should not only make procedural changes when the data prove current interventions are ineffective, but also make decisions to modify an objective to yield the desired outcome more quickly (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2, 4). For example, if a learner has spent a significant amount of time working on tying their shoes with limited success, there are numerous adaptations that can be made to still allow them to independently complete the task of putting on one’s own shoes (e.g., elastic/drawstring shoelaces, stylish slip-on shoes). Likewise, if a learner is struggling with the step of using a washing machine that includes filling a cup of liquid laundry detergent, a commonly used adaptation such as Tide PODS^® could be used to circumvent this difficulty and more quickly lead to independence. Efficiency should be prioritized so that skills can be quickly mastered, and new skills can be targeted. Practitioners have such little time during childhood and adolescence to affect outcomes in adulthood, simply in terms of years of available intensive and funded treatment (Marsack-Topolewski & Weisz, 2020; Shattuck et al., 2020). We do not have time to waste.

Individual Responsibility in Interpreting the Ethics Code vs. Necessary Systemic Changes

The previous sections described how behavior analysts can help to improve outcomes in adulthood for those on the autism spectrum by shaping their practice around proposed ethical themes that are supported by the current Code (BACB, 2020). In addition to individual responsibility to uphold these best-practice themes, it is proposed that several systemic changes to our field could help support these improvements in practice. First, we can provide prospective and current behavior analysts with resources such as this article, as well as texts or ethical handbooks that could be developed to go hand in hand with the Code that include specific attention to how to guide skill acquisition programming as it relates to improving long-term outcomes of adolescents and adults with ASD. Because it would be helpful if funding sources were mandated to support adaptive behavior skills that have been shown to positively affect outcomes, it would be beneficial to also resource behavior analysts, ABA-business owners, billing specialists, etc. with a curated collection of research to refer to that supports the benefit of adaptive behavior skills (e.g., Bolte & Poustka, 2002; Dell’Armo & Tassé, 2019; Paul et al., 2004), the effectiveness of ABA with older learners (e.g., Ivy & Schreck, 2016), as well as research that supports teaching such skills in natural environments (e.g., Cowan & Allen, 2007) to aid in their efforts to advocate for funding to support these important skills. Additional research would be helpful to add to the small but emerging literature base in these areas, including large-scale randomized controlled trials or longitudinal outcome studies to support efforts in advocating for more funding and resources across the lifespan. Second, we can provide more forums to facilitate the exchange of this information and networking opportunities to allow behavior analysts to discuss and expand their knowledge in these areas, including platforms to connect practitioners with experts who may provide consultation and/or mentorship, special interest groups, as well as focused continuing education opportunities to further disseminate these points.

Third, all of the concerns discussed earlier are directly relevant to training the future of our field. If behavior analysts who work with individuals with ASD do not practice in ethical ways that promote improved outcomes for this population in adulthood, they will not be able to train the next cohort of behavior analysts to do so (see BACB, 2020, standards 4.02,4.06; core principle 4). If we want to ensure best practice in the field within this population, it may make sense to consider making modifications to adjust the trickle-down effect that determines what behaviors end up in newly minted BCBAs’ repertoires who intend to work with individuals with autism. For example, the BACB task list determines what is on the BACB exam, which drives higher education course requirements, supervision guidelines, etc., yet there are no current requirement that specific expertise be developed to work within the autism population, and (as previously stated) this is where three quarters of our field practices (BACB, 2020).

Historically Relevant Contributions that Are Not Being Reliably Applied in Behavior Analytic Practice

What is interesting about the suggestions made within this article is that they do not represent values or ideas that are inherently “new.” Various calls to action have been published, and practice movements have taken place both within the field of applied behavior analysis and in related disciplines that support the rights of individuals with disabilities, including autism, to be taught the applied, socially validated skills needed to function independently in adulthood. Yet, these efforts seemed to have lacked sufficient impact, because little improvement in the outcome data has been noted. Some of these contributions are discussed in the following sections. The reader is encouraged to note the parallels that can be seen between these sections and what the authors have proposed in the present article, and consider historical contributions as additional support to this article’s purpose.

Behavior Analytic Contributions

Over 5 decades ago, the central importance of targeting and prioritizing functional skills and honoring the rights of clients was put forth in our peer-reviewed literature. First, in what is often referred to as the defining article of our field, Baer et al. (1968) asserted that behavior analytic work should result in strong, socially significant, and generalizable outcomes; this surely applies to a focus on positive, long-term outcomes in adulthood (see BACB, 2020, standards 2.01, 2.15, 2.18, 3.01; core principles 1, 2). Related to choosing goals and procedures that matter, Wolf (1978) defined the concept of social validity and urged the field that that society should validate our interventions on at least three levels: (1) the goals we prescribe; (2) the procedures we use; and (3) the effects of treatment (p. 206; see BACB, 2020, standards 2.01, 2.14, 2.15, 3.01; core principles 1, 2). He further argued that as an applied science, we should target only those skills most important to people, and be “dedicated to helping people become better able to achieve their reinforcers" (Wolf, 1978, p. 106). Numerous authors over the years provided extensive guidelines for how to measure social validity and translate the results of these measurements into practice that are still applicable today (e.g., Bernstein, 1989; Fawcett, 1991; Gresham & Lopez, 1996; Kazdin, 1980).

In addition, Van Houten et al.’s (1988) seminal article (“The Right to Effective Behavioral Treatment”) outlined six rights to which all recipients of behavior-analytic intervention are entitled. Of these rights, at least two directly relate to selecting goals that are relevant to improving outcomes in adulthood; these include, “The right to services whose overriding goal is personal welfare,” and “The right to programs that teach functional skills” (p. 382). Regarding personal welfare, Van Houten et al. (1988) stated, “The primary purpose of behavioral treatment is to assist individuals in acquiring functional skills that promote independence. Both the immediate and long-term welfare of an individual are taken into account through active participation by the client or an authorized proxy in making treatment-related decisions" (p. 382) (see BACB, 2020, standards 2.01, 3.01; core principles 1, 2). In describing the right to functional programs, the authors noted that the ultimate goal of behavioral services is to help ensure the individual can function effectively in their immediate environment, as well as within society (p. 82). Likewise, Bannerman et al. (1990) argued for the rights of individuals with disabilities to exercise personal liberties, explaining that all have the right to, “eat too many doughnuts and take a nap” (p. 80). Paramount within these rights is the freedom that should be afforded to exercise choice within one’s own programming and exert control over one’s own life. This included having input into what skills will be taught and how (see BACB, 2020, standards 2.01, 2.13, 2.14, 3.01; core principles 1, 2). In addition, the authors argued for teaching independent living skills and other functional, preferred behaviors (Bannerman et al., 1990).

Contributions from Related Disciplines

Researcher-practitioners such as Lou Brown and colleagues provided valuable insight into the early navigation of what and how to teach individuals with disabilities after inclusion efforts began in the United States (O’Brien & O’Brien, 2000). It is notable that, as previously mentioned, in 1976 Brown et al. described what was referred to as the criterion of ultimate functioning as, “the ever-changing, expanding, localized, and personalized cluster of factors that each person must possess in order to function as productively and independently as possible in socially, vocationally, and domestically integrated adult community environments” (p. 8). Such a standard by which to measure the importance of goals to target provides a valuable example that can still be called upon today. Some, although surely not all, additional contributions related to several movements within the special education/disability fields that can be called upon for support and guidance for affecting quality outcomes will be reviewed in the following sections.

Person-Centered Planning

Person-centered planning approaches were first developed in the late 1970s to the early 1990s in order to help practitioners develop collaborative, goal-oriented, individualized programs to support all people, regardless of their level of disability (Keyes & Owens-Johnson, 2003; O’Brien, 1987). Common agendas of the first person-centered planning approaches included: increasing choice, advocating depersonalizing labels and difference-making procedures, honoring the voices of the person and those who know the person best, building relationships, individualizing support based on high expectations, and demanding that agencies adopt new forms of services (O’Brien & O’Brien, 2000; see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 3.01; core principles 1, 2). These efforts sought to develop skills and knowledge needed to support a quality life in the community for all individuals, with collaborative efforts focused on community presence, participation, positive relationships, respect, and competence (Claes et al., 2010; O’Brien & O’Brien, 2000). Analysis of the research in person-centered planning suggested that this approach has had a positive, but moderate, impact on personal outcomes (Claes et al., 2010). Thus, the values and efforts of person-centered planning approaches that were put in place decades ago are clearly in line with the values of an ethical behavior analyst and the intentions of the field of behavior analysis to value and benefit the individual (see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 3.01; core principles 1, 2).

Positive Behavioral Supports (PBS)

From its beginnings, positive behavior supports (PBS) has focused on targeting skill acquisition goals that promote meaningful outcomes and quality of life for individuals with disabilities, including those with autism and their families (Carr et al., 2002). PBS emerged in the mid-1980s as an alternative to the prevailing ABA practices that emphasized the manipulation of consequences, often aversive, to produce behavior change (Kincaid et al., 2016). Carr et al. (2002) defined PBS as "an applied science that uses educational methods to expand an individual's behavior repertoire and systems change methods to redesign an individual's living environment first to enhance the individual's quality of life and, second, to minimize his or her problem behavior" (p. 4). PBS relies on strategies that are respectful of a person's dignity and overall well-being, drawn primarily from behavioral, educational, and social sciences that include progress monitoring at the individual level and at the larger systems level (e.g., families, classrooms, schools, social, service programs, and facilities; Meyer et al., 2021; Pinkelman et al., 2020; see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 2.18, 3.01; core principles 1, 2). It has been suggested that PBS is a framework for applied behavior analytical practices at scale (Horner & Sugai, 2015) that is important for behavior analysts to understand because it provides a data-based framework to improve the effectiveness and efficiency of applied behavior analysis interventions (Putnam & Kincaid, 2015). Although keeping the rigor of our science intact, it would appear that examining the relevant contributions of PBS could be helpful to behavior analysts today seeking to provide meaningful treatment for individuals on the spectrum (see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 2.18, 3.01; core principles 1, 2).

Self-Determination

In the 1990s, an educational emphasis was placed on promoting self-determination, which emerged from federal initiatives mandating active student involvement in transition goals, educational planning, and decision making for adolescents with disabilities (Wehmeyer, 1998; Wehmeyer & Schalock, 2001). An evolving definition of self-determination was proposed by Martin and Marshall (1995) that included knowing how to choose; knowing what one wants, how to get it, and being assertive in doing so; evaluating progress towards goals; and adjusting performance to attain these goals (Wehmeyer & Schalock, 2001; see BACB, 2020, standards 2.01, 2.09, 2.14; core principles 1, 2). Wehmeyer and Schalock (2001) suggested that one of the reasons adults with disabilities have poor outcomes (e.g., employment, independent living, community integration) after leaving school is because they have not been adequately prepared to become self-determined. Self-determination behaviors were identified as a valid outcome measure and closely related to higher QoL (Wehmeyer & Schwartz, 1997). In an effort to describe self-determination in behavioral science terms, in particular for those with less developed verbal skills, Baer (1998) stated simply. “The proposal is to find out what people with severe disabilities want and to incorporate as many of their wants as feasible.... The proposal is to develop our sensitivity to the various forms of communication used by people with severe disabilities so that we may do more of what they want and impose on them less of what we assume they want or want them to want” (p. 51). Although the concept of self-determination was emphasized in the 1990s, advocates for those with disabilities began emphasizing the ability to be self-determined as early as the 1970s (Ward, 2005). For example, Perske (1972) discussed that individuals of diverse abilities have the right to the dignity of risk and discussed how situations involving appropriate and reasonable risk can, and should, be incorporated into meaningful programming (see BACB, 2020, standard 2.15; core principle 1, 2). Thus, a focus on independence in making choices (at any level of ability) that leads to increased QoL was put out in the literature dating back decades; this remains relevant today in developing programming that leads to improved adult outcomes.

Summary

Over the next decade, it is estimated that an additional 707,000–1,116,000 teens will enter the world of adulthood (Autism Speaks, n.d.a). Despite these ever-increasing numbers, outcomes for adults on the spectrum remain poor, research remains slim, funding remains low, and resources remain allocated elsewhere (Gerhardt & Lainer, 2011; Howlin, 2021; Shattuck et al., 2020). However, while the number of adults on the spectrum continues to increase, so does the number of BACB certificants (BACB, n.d.). The field of behavior analysis is in a position to help and, it can be argued, is ethically required to. Behavior analysts are encouraged to change the way we practice, by (1) making needed modifications to what skills we teach, prioritizing those skills that are most meaningful for our clients’ lives both now and in their future; and (2) ensuring that the most effective procedures are used to teach the most important skills. In order to affect change, modifications should be made not only on an individual practitioner level, but also on a larger scale through resourcing behavior analysts and other advocates of our field with relevant research, providing forums for dissemination and networking, and shaping the future of our field by ensuring specific expertise is developed in those behavior analysts who choose to work within the autism population. The authors hope that this article will be used as a resource to aid in supervision and/or coursework, or as a guide in creating continuing education content. It is also the hope that this article will shed light on a real problem within the primary population served by the field of ABA, sparking interest that may lead to more research and practice within this population. Finally, it is the hope of the authors that this article will build on work done previously and serve as a point of renewed refocusing toward prioritizing meaningful treatment that leads to improved outcomes in adulthood for individuals with ASD.

Authors' Contributions

The first draft of the manuscript was written by Shanna Bahry and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Data Availability

Not applicable.

Code Availability

Not applicable.

Declarations

Conflicts of Interest/Competing Interests

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Additional declarations related to ethics/consent are not applicable, because this article did not involve the use of human and/or animal participants.